Coccidioidomycosis Among Cast and Crew Members at an Outdoor Television Filming Event — California, 2012

In March 2013, the California Department of Public Health (CDPH) identified two Doctor's First Reports of Occupational Injury or Illness (DFRs) regarding Los Angeles County residents who had worked at the same jobsite in January 2012 and had been evaluated for possible work-associated coccidioidomycosis (valley fever). Occupational exposure to Coccidioides, the causative fungi, typically is associated with soil-disrupting activities. The physicians noted that both workers were cast or crew members filming a television series episode, and the site of possible exposure was an outdoor set in Ventura County, California. On the basis of their job titles, neither would have been expected to have been engaged in soil-disrupting activities. Los Angeles County Department of Public Health (LACDPH) conducted an outbreak investigation by using CDPH-provided occupational surveillance records, traditional infectious disease surveillance, and social media searches. This report describes the results of that investigation, which identified a total of five laboratory-confirmed and five probable cases linked to this filming event. The employer and site manager were interviewed. The site manager stated that they would no longer allow soil-disruptive work at the site and would incorporate information about the potential risk for Coccidioides exposure onsite into work contracts. Public health professionals, clinicians, and the television and film industry should be aware that employees working outdoors in areas where Coccidioides is endemic (e.g., central and southern California), even those not engaged in soil-disruptive work, might be at risk for coccidioidomycosis.


event.
A copy of the letter sent to the employee was included with the DFR. Patient 2, a camera operator who had sought evaluation at an emergency department on February 24 after a 2-week history of cough, joint aches, and muscle pain, was identified by review of the health-care provider's notes as having worked at the same outdoor filming event; patient 2 was not the patient referenced in the original letter.
Subsequent review of information obtained from the California Department of Industrial Relations (DIR) identified six additional workers with the same employer who had sought evaluation for possible work-associated coccidioidomycosis. Because all workers identified were residents of Los Angeles County, CDPH informed LACDPH of the possible outbreak, and LACDPH led the local investigation.
A confirmed outbreak case was defined as a laboratoryconfirmed illness (including clinical presentation with an influenza-like illness, pneumonia or pulmonary lesion, erythema nodosum or erythema multiforme rash, or extrapulmonary disease) meeting the 2011 Council of State and Territorial Epidemiologists coccidioidomycosis surveillance case definition (3) that occurred in a person who was present at the filming event (performing site preparation work during January 15-16 or at the filming event during January 17-19). A probable case was a clinically compatible illness in a person present at the filming event. Patients were identified through review of DFRs and information obtained from DIR, review of social media, or interview with another patient. LACDPH contacted the employer and obtained cast and crew rosters, which were cross-referenced with the LACDPH coccidioidomycosis surveillance database. Patients, or family contacts of a decedent, were interviewed by LACDPH, and the employer and filming site manager were interviewed by CDPH and LACDPH.
Eight patients initially were identified through review of DFRs and information obtained from DIR. One was identified by review of social media, wherein the patient had posted details about his hospitalization, and one was identified by another patient as a relative (nonemployee) who had been onsite during the filming event. The patient referenced in the employer letter was among those with laboratory-confirmed illness. Of 10 persons identified, seven were interviewed; three could not be contacted. LACDPH ascertained five confirmed and five probable cases. The employee roster indicated 655 workers were associated with that particular television episode. The attack rate for all identified cases was 1.5%.
Median time to symptom onset was 11 days (range = 3-28 days), as determined by interviews of seven patients and medical record review for two patients (Table 1); an estimate could not be made for one patient. Two patients were hospitalized, one for 2 days and one for 4 weeks. The seven interviewed patients reported symptom duration ranging from 1 week to 6 months (Table 2) and reported recovering fully from their illness. One patient had died of an unrelated illness. Five of the interviewed patients reported dry, dusty conditions during the filming event. Only two of the interviewed patients, a construction coordinator and a prop or set maker, engaged in soil-disrupting activities (digging and moving dirt). However, substantial soil-disruptive work, including grading and digging and filling a mud pit, occurred shortly before the filming event. Furthermore, the site manager reported to LACDPH and CDPH that substantial dust from an adjacent mining company blew onto the site daily. CDPH has not identified any cases among employees of the mine at this time.
The employer responded promptly to the initial identification of one illness among cast and crew by sending the original letter to employees, encouraging anyone with symptoms to seek medical evaluation. After interviewing the employer's environmental health and safety manager and discussing future prevention practices, CDPH provided a "Preventing Work-Related Coccidioidomycosis (Valley Fever)" fact sheet (4) to the employer for integration into their Injury and Illness Prevention Program (IIPP). The site owner informed LACDPH and CDPH that they had already halted digging and excavation at the site. After consultation with CDPH, he stated they would no longer allow soil-disruptive work at the site and would advise future film crews of the potential risk for Coccidioides exposure onsite. CDPH also advised the site owner to consult the local air pollution control district for assistance in mitigating offsite dust.

Discussion
The outbreak described in this report was identified by review of DFRs, using a pilot occupational coccidioidomycosis surveillance system recently established by CDPH. Title 17 of California's Code of Regulations requires health-care providers to report coccidioidomycosis diagnoses and outbreaks to the local health jurisdiction (5). Although coccidioidomycosis diagnoses for four of the five confirmed cases were reported to LACDPH, the outbreak was only detected by use of a nontraditional database for occupational surveillance. CDPH previously had used workers' compensation claims data to identify these industries as having the highest incidence of coccidioidomycosis: mining, quarrying, and oil and gas extraction; public administration; agriculture, forestry, fishing, and hunting; and construction (1). Coccidioidomycosis outbreaks among archaeologists (6,7), military personnel (8,9), and construction workers (10) have been described previously. This outbreak investigation identified occupations and an industry not previously known to be at risk.
The outbreak described in this report is illustrative of the risk to employees working outdoors in Coccidioides-endemic areas. Although most patients did not engage in soil-disruptive activities, substantial soil disruption immediately preceded the filming event, and the site owner reported ongoing dust intrusion from a neighboring mining company onto the filming site. Because no reliable methods for environmental Coccidioides sampling are available, identifying the source of the spores was not possible. CDPH previously had recommended a comprehensive approach to reducing incidence and severity of work-associated coccidioidomycosis (4). The approach includes limiting workers' exposure to outdoor dust by controlling dust generation at the source (e.g., continuous soil wetting), providing employee training, and consistently enforcing an IIPP, which includes providing respiratory protection with particulate filters. However, the majority of patients in this outbreak were not involved in excavation or set  construction and might not have been considered at increased risk for coccidioidomycosis in the existing IIPP. Nevertheless, working at a site immediately after soil disturbance might expose workers to Coccidioides spores, and a comprehensive IIPP for these employees should include 1) covering spoils piles and wetting disturbed areas, 2) establishing criteria for suspending work on the basis of wind and dust conditions, and 3) prompt disease recognition and referral to occupational medicine clinics for evaluation, treatment, and follow-up (1,4). Clinicians, including occupational health providers, should be aware that work-associated coccidioidomycosis can occur among patients who do not actively engage in soil-disruptive activities and include relevant information (e.g., employer, worksite, industry, occupation, and other information on activities or locations that might be related to exposure) when reporting cases to local health officials.
What is already known on this topic?
Work-associated Coccidioides infections and outbreaks have been linked to soil-disrupting activities, including construction, in areas where Coccidioides is endemic.
What is added by this report?
Occupational surveillance identified an outbreak of coccidioidomycosis in an unexpected industry (i.e., film and television). Employees working outdoors in any industry, even those not actively engaged in soil disruption, might be exposed to Coccidioides where it is endemic.
What are the implications for public health practice?
Occupational injury and illness surveillance can identify outbreaks not otherwise detected by traditional infectious disease surveillance. Education about coccidioidomycosis, including signs and symptoms, and exposure prevention measures should be implemented at outdoor worksites in areas where Coccidioides is endemic, including worksites of industries and occupations not typically associated with soil-disrupting activities. Health-care providers should consider the possibility of work-relatedness among patients with coccidioidomycosis diagnoses and note employer, work location, industry, and occupation when reporting cases.
Since 2010, Nigerian state and federal governments and the international community have been responding to an outbreak of lead poisoning caused by the processing of lead-containing gold ore in Zamfara State, Nigeria, that resulted in the deaths of approximately 400 children aged ≤5 years (1). Widespread education, surveys of high-risk villages, testing of blood lead levels (BLLs), medical treatment, and environmental cleanup all have been implemented. To evaluate the success of these remediation efforts in reducing the prevalence of lead poisoning and dangerous work practices, a population-based assessment of children's BLLs and ore processing techniques was conducted during June-July 2012. The assessment found few children in need of medical treatment, significantly lower BLLs, and substantially less exposure of children to dangerous work practices. Public health strategies designed to identify and treat children with lead poisoning, clean up existing environmental hazards, and prevent children from being exposed to dangerous ore processing techniques can produce a sustained reduction in BLLs.
The 2010 outbreak of lead poisoning in Zamfara State caused by unsafe processing of lead-containing gold ore resulted in severe neurologic illness and death in children. When processed dry with low technology methods, the gold ore produced fine particles that contaminated water and food crops and were easily inhaled or ingested during normal hand-to-mouth activities common among toddlers (2).
When inhaled or ingested, lead can cause damage to the brain, kidneys, bone marrow, and other body systems in young children. In infants and children, BLLs as low as 5 µg/dL have been associated with developmental problems, including impaired cognitive function, behavioral difficulties, impaired hearing, and reduced stature (3). BLLs ≥75µg/dL can cause coma, convulsions, and death. No safe BLL has been identified for children (4).
During June-July 2012, the Zamfara State Ministry of Health, Nigerian Field Epidemiology and Laboratory Training Program, and CDC collaborated to conduct a representative, cross-sectional, population-based, multistage stratified cluster design survey to estimate the geometric mean (GM) BLLs of children living in Zamfara State aged ≤5 years. Investigators also examined the extent of exposure to ore processing methods that generate dust (i.e., crushing ore, dry grinding ore using power flour grinders, and open air drying of ore), and they examined the ore processing practices among the children's mothers, an important factor because ore processing inside the family compound is a female role in this population. Because mothers also are responsible for child care, ore processing among mothers is a risk factor for young children who eat, sleep, and play within the compound.
To create systematic samples for village-level and familylevel surveys, a total of 112 villages initially were selected from among the 14 local government areas in Zamfara State, proportionate to the population of the areas, using ambient population distribution software (5). An additional 10 villages were selected as potential replacements should some selected villages be inaccessible or unsafe, bringing the total to 122. To obtain population-based estimates of children's blood and environmental lead levels, one child in each of seven systematically selected families was surveyed in more detail from each of 56 villages systematically selected from among the 122 villages, for a total of 392 children in the study sample.* Venous blood samples were collected from children aged ≤5 years. BLLs were analyzed using inductively coupled plasma mass spectroscopy, with a lower limit of detection of 0.25 µg/dL. The precision and quality assurance measures used have been described previously (6). GM BLLs were analyzed for correlation with exposure to different ore processing methods, with statistical significance determined at p<0.05. The study protocol was approved by the National Health Research Ethics Committee of Nigeria and the CDC Institutional Review Board.
Among the 392 children aged ≤5 years, the mean age was 35 months. The mothers of 69 (17.6%) children were involved in ore processing activities. Sixty-one (15.6%) mothers used processing techniques that generated large amounts of dust, and 17 (4.3%) mothers processed ore using dust-generating techniques within the family compound.
A history of convulsions was reported in 90 (23.0%) children. Thirty-four of the children lived in villages that used dust-generating ore processing methods, 40 lived in villages

Assessment of Blood Lead Levels Among Children Aged ≤5 Years -Zamfara State, Nigeria, June-July 2012
Muhammed Bashir, MD 1 , Nasir Umar-Tsafe, MSc 1 , Kabiru Getso, MBBS 1 , Ibrahim M. Kaita, MSc 1 , Abdulsalami Nasidi, PhD 2 ; Nasir Sani-Gwarzo MD 2 ; Patrick Nguku, MD 3 , Lora Davis, DVM 3 , Mary Jean Brown ScD 4 (Author affiliations at end of text) * A sample size of 46 villages had been determined large enough to estimate the prevalence of elevated BLLs ≥10 µg/dL (then defined as the CDC BLLs of concern). An additional 10 villages were added to the sample in the event some of the 46 selected villages were inaccessible or unsafe, bringing the total to 56 villages, each with seven children, for a total of 392 children in the sample.
The GM BLL of the children whose mothers were involved in dust-generating ore processing activities was 8.5 µg/dL (standard deviation [SD] = 11.1), compared with 6.4 µg/dL (SD = 5.3; p<0.001) among those whose mothers used nondust-generating ore processing methods (Table). When dust-generating activities were conducted within the family compound, the GM BLL in children was 8.9 µg/dL (SD = 9.8). All four children with BLLs ≥45 µg/dL had mothers involved in dust-generating activities within the family compound.
Although the use of mercury for gold extraction to amalgamate gold was not defined as a dust-generating activity, children living in villages where mercury was used had BLLs significantly higher than children where gold ore was not processed (GM 11.2 µg/dL [SD = 5.1] compared with 3.4 µg/dL [SD = 5.1], p<0.05). Additionally, for children living in villages where excess mercury was burned off the ore, the GM BLL tended to be significantly higher (GM 13.1 µg/dL [SD = 16.6]), compared with children living in villages in which mercury was not used to amalgamate gold.

Discussion
The 2010 outbreak of lead poisoning in Zamfara State was unprecedented in recent decades. In two investigations in 2010 conducted to identify villages where risk for lead poisoning was extremely high, one found that 97% of children had BLLs ≥45 µg/dL, and the second found that, among ore processing Abbreviations: GM BLL = geometric mean blood lead level; SD = standard deviation. * Dust-generating activities include breaking ore, grinding ore, and drying ore. † Non-dust-generating activities include washing ore and mercury amalgamation. § Defined as no ore processing within 1.26 mi (2 km) of the village.
villages, 30% of children had BLLs ≥45 µg/dL, but no children in villages that did not process ore had BLLs this high. (8) Since 2010, a team of international, Nigerian federal, and Nigerian state public health agencies, environmental remediation specialists, health-care providers, and educators has worked to reduce BLLs in young children. These efforts have resulted in identification of lead contamination in approximately 50 villages, cleanup of environmental lead contamination in 11 villages, chelation therapy for children with BLLs ≥45 µg/dL, widespread public education campaigns, and training for local workers responsible for testing and remediation activities (9).
In the assessment described in this report, 74% of the 56 villages were involved in the gold trade, and the GM BLL was significantly higher among children whose mothers processed ore using dust-generating methods. Few families (20 [5%] compared with 84 [71%] in 2010) (1) were processing ore within the family compound, where children aged ≤5 years spend most of their time, and three of the 20 families used non-dust-generating ore processing methods. However, the highest GM BLLs were found among children who lived in villages where mothers used certain non-dust-generating methods, such as amalgamating ore using mercury or burning excess mercury off the ore; the high GM BLLs might have resulted from toxic lead fumes released during burning.
Although work remains, much has been done to address the problem of lead exposure in Zamfara State. New and safer processing techniques that control dust and residual ore wastes, a better understanding of potential exposure to lead-contaminated foodstuffs, continued BLL surveillance, chelation therapy when warranted, and environmental cleanup of hazardous sites remain critical (9). When such strategies are successfully implemented, a sustained reduction of BLLs in children can be achieved. What is already known on this topic?
Processing of lead-containing gold ore using dust-generating methods caused the deaths of approximately 400 children from lead poisoning in Zamfara State, Nigeria, in 2010 and left thousands of others with severe disabilities. The Nigerian and Zamfara State governments, in collaboration with international organizations including CDC, have been working to identify and treat affected children, clean up the hazardous processing sites, and educate the community about the dangers of lead.
What is added by this report?
This assessment found that most families are using safer ore processing methods and blood lead levels among young children are lower than those found in 2010. Only 20 families (5%) were processing ore within the family compound, where children aged ≤5 years spend most of their time, compared with 84 families (71%) in 2010.
What are the implications for public health practice?
Collaboration between governments and the international community can prevent lead poisoning in children. When strategies such as use of processing techniques that control dust and residual ore wastes, continued blood lead surveillance, chelation therapy when warranted, and environmental cleanup of hazardous sites are successfully implemented, a sustained reduction of blood lead levels in children can be achieved.
In addition to culture-confirmed infections (some with a positive CIDT result), there were 1,487 reports of positive CIDTs that were not confirmed by culture, either because the specimen was not cultured at either the clinical or public health laboratory or because a culture did not yield the pathogen. For 1,017 Campylobacter reports in this category, 430 (42%) had no culture, and 587 (58%) were culture-negative. For 247 STEC reports, 59 (24%) had no culture, and 188 (76%) were culture-negative. The Shiga toxin-positive result was confirmed for 65 (34%) of 192 broths sent to a public health laboratory. The other reports of positive CIDT tests not confirmed by culture were of Shigella (147), Salmonella (69), Vibrio (four), Listeria (two), and Yersinia (one).

Discussion
The incidence of laboratory-confirmed Salmonella infections was lower in 2013 than 2010-2012, whereas the incidence of Vibrio infections increased. No changes were observed for infection with Campylobacter, Listeria, STEC O157, or Yersinia, the other pathogens transmitted commonly through food for which Healthy People 2020 targets exist. The lack of recent progress toward these targets points to gaps in the current food safety system and the need for more food safety interventions.
Although the incidence of Salmonella infection in 2013 was lower than during 2010-2012, it was similar to 2006-2008, well above the national Healthy People target. Salmonella organisms live in the intestines of many animals and can be transmitted to humans through contaminated food or water or through  (4), but about 50% of domestically acquired infections are transmitted through food, most commonly oysters (5). Foodborne infections can be prevented by postharvest treatment of oysters with heat, freezing, or high pressure, by thorough cooking, or by not eating oysters during warmer months (6). During the summers of 2012 and 2013, many V. parahaemolyticus infections of a strain previously traced only to the Pacific Northwest were associated with consumption of oysters and other shellfish from several Atlantic Coast harvest areas. ¶ ¶ V. alginolyticus, the second most common Vibrio reported to FoodNet in 2013, typically causes wound and soft-tissue infections among persons who have contact with water (7).
The continued decrease in the incidence of postdiarrheal HUS has not been matched by a decline in STEC O157 infections. Possible explanations include unrecognized changes in surveillance, improvements in management of STEC O157 diarrhea, or an actual decrease in infections with the most

FIGURE 1. Estimated percentage change in incidence of culture-confirmed bacterial and laboratory-confirmed parasitic infections in 2013 compared with average annual incidence during 2010-2012, by pathogen -Foodborne Diseases Active Surveillance Network, United States
Abbreviations: CI = confidence interval; STEC = Shiga toxin-producing Escherichia coli. * No significant change = 95% CI is both above and below the no change line; significant increase = estimate and entire CI are above the no change line; significant decrease = estimate and entire CI are below the no change line. virulent strains of STEC O157. It is possible that more stool specimens are being tested for STEC, resulting in increased detection of milder infections than in the past. Continued surveillance is needed to determine if this pattern holds. CIDTs are increasingly used by clinical laboratories to diagnose bacterial enteric infections, a trend that will challenge the ability to identify cases, monitor trends, detect outbreaks, and characterize pathogens (8). Therefore, FoodNet began tracking CIDT-positive reports and surveying clinical laboratories about their diagnostic practices. The adoption of CIDTs has varied by pathogen and has been highest for STEC and Campylobacter. Positive CIDTs frequently cannot be confirmed by culture, and the positive predictive value varies by the CIDT used. For STEC, most specimens identified as Shiga toxin-positive were sent to a public health laboratory for confirmation. However, for other pathogens the fraction of specimens from patients with a positive CIDT sent for confirmation likely is low because no national guidelines regarding confirmation of CIDT results currently exist. As the number of approved CIDTs increases, their use likely will increase rapidly. Clinicians, clinical and public health laboratorians, public health practitioners, regulatory agencies, and industry must work together to maintain strong surveillance to detect dispersed outbreaks, measure the impact of prevention measures, and identify emerging threats.
The findings in this report are subject to at least five limitations. First, health-care-seeking behaviors and other characteristics of the population in the surveillance area might affect the generalizability of the findings. Second, some agents transmitted commonly through food (e.g., norovirus) are not monitored by FoodNet because clinical laboratories do not routinely test for them. Third, the proportion of illnesses transmitted by nonfood routes differs by pathogen; data provided in this report are not limited to infections from food. Fourth, in some fatal cases, infection with the enteric pathogen might not have been the primary cause of death. Finally, changes in incidence between periods can reflect year-to-year variation during those periods rather than sustained trends.
Most foodborne illnesses can be prevented, and progress has been made in decreasing contamination of some foods and reducing illness caused by some pathogens since 1996, . Because most chicken is purchased as cut-up parts, USDA-FSIS conducted a nationwide survey of raw chicken parts in 2012 and calculated an estimated 24% prevalence of Salmonella (9). In 2013, USDA-FSIS released its Salmonella Action Plan that indicates that USDA-FSIS will conduct a risk assessment and develop performance standards for poultry parts during 2014, among other key activities (10). The Food Safety Modernization Act of 2011 gives FDA additional authority to regulate food facilities, establish standards for safe produce, recall contaminated foods, and oversee imported foods; it also calls on CDC to strengthen surveillance and outbreak response (1). For consumers, advice on safely buying, preparing, and storing foods prone to contamination is available online.
The incidences of infection caused by Campylobacter, Salmonella, Shiga toxin-producing Escherichia coli O157, and Vibrio are well above their respective Healthy People 2020 targets. Foodborne illness continues to be an important public health problem.
What is added by this report?
In 2013, a total of 19,056 infections, 4,200 hospitalizations, and 80 deaths were reported to the Foodborne Diseases Active Surveillance Network (FoodNet). For most infections, incidence was highest among children aged <5 years. In 2013, compared with 2010-2012, the estimated incidence of infection was unchanged overall, lower for Salmonella, and higher for Vibrio infections, which have been increasing in frequency for many years. The number of patients being diagnosed by cultureindependent diagnostic tests (CIDT) is increasing.
What are the implications for public health practice?
Reducing the incidence of foodborne infections requires greater commitment and more action to implement measures to reduce contamination of food. Monitoring the incidence of these infections is becoming more difficult because some laboratories are now using CIDTs, and some do not follow up a positive CIDT result with a culture.
In 2005, CDC and the Food and Drug Administration (FDA) issued a warning regarding the use of Lyme disease tests whose accuracy and clinical usefulness have not been adequately established (1). Often these are laboratory-developed tests (also known as "home brew" tests) that are manufactured and used within a single laboratory and have not been cleared or approved by FDA. Recently, CDC has received inquiries regarding a laboratory-developed test that uses a novel culture method to identify Borrelia burgdorferi, the spirochete that causes Lyme disease. Patient specimens reportedly are incubated using a two-step pre-enrichment process, followed by immunostaining with or without polymerase chain reaction (PCR) analysis. Specimens that test positive by immunostaining or PCR are deemed "culture positive" (2). Published methods and results for this laboratory-developed test have been reviewed by CDC. The review raised serious concerns about false-positive results caused by laboratory contamination and the potential for misdiagnosis (3).
CDC recommends that laboratory tests cleared or approved by FDA be used to aid in the routine diagnosis of Lyme disease. A complete searchable list of such tests is available online (4).
When evaluating testing options, providers and their patients might be confused by the distinction between Clinical Laboratory Improvement Amendments (CLIA) certification of laboratories and FDA clearance or approval of specific tests. CLIA certification of a laboratory indicates that the laboratory meets a set of basic quality standards.* It is important to note, however, that the CLIA program does not address the clinical validity of a specific test (i.e., the accuracy with which the test identifies, measures, or predicts the presence or absence of a clinical condition in a patient). † FDA clearance/approval of a test, on the other hand, provides assurance that the test itself has adequate analytical and clinical validation and is safe and effective. § When laboratory testing is indicated, CDC recommends two-tier serologic testing for the diagnosis of Lyme disease. Two-tier testing consists of an FDA-cleared enzyme immunoassay (EIA) that, if positive or equivocal, is followed by an FDA-cleared immunoblot test, commonly known as a "Western blot" test. Results are considered positive only when both the EIA and Western blot are positive (5). Culture and PCR of clinical specimens are recommended only in certain rare circumstances (6).
CDC encourages researchers to work with FDA to develop new or improved tests for the diagnosis of Lyme disease. As with any diagnostic test, it is critical that new tests for Lyme disease have adequate analytical and clinical validation to avoid misdiagnosis and improper treatment of patients. Bats provide vital ecologic services that humans benefit from, such as seed dispersal and pest control, and are a food source for some human populations. However, bats also are reservoirs for a number of high-consequence zoonoses, including paramyxoviruses, filoviruses, and lyssaviruses (1). The variety of viruses that bats harbor might be related to their evolutionary diversity, ability to fly large distances, long lifespans, and gregarious roosting behaviors (1,2). Every year a festival takes place in Idanre, Nigeria, in which males of all ages enter designated caves to capture bats; persons are forbidden from entering the caves outside of these festivities. Festival participants use a variety of techniques to capture bats, but protective equipment rarely is used, placing hunters at risk for bat scratches and bites. Many captured bats are prepared as food, but some are transported to markets in other parts of the country for sale as bushmeat. Bats also are presented to dignitaries in elaborate rituals. The health consequences of contact with these bats are unknown, but a number of viruses have been previously identified among Nigerian bats, including lyssaviruses, pegiviruses, and coronaviruses (2)(3)(4). Furthermore, the caves are home to Rousettus aegyptiacus bats, which are reservoirs for Marburg virus in other parts of Africa (5).

Assessment of Potential Zoonotic Disease Exposure and Illness Related to an Annual Bat
In February 2013, a team composed of members of the Nigerian Field Epidemiology and Laboratory Training Program (FELTP), the Nigerian Federal Ministry of Health, and CDC traveled to Idanre to assess potential zoonotic disease exposures and illnesses related to the festival. Interviews conducted with 54 persons who have participated in the festival as bat hunters revealed that 43 (80%) had a history of bat scratches and 39 (72%) had a history of bat bites. Only one (1.9%) hunter reported ever having received rabies vaccine. None of the hunters knew of a person who had acquired a fatal illness as a result of contact with bats or entering the caves. Additional data analyses and serologic assays are pending.
Driven by socioeconomic and environmental factors, the emergence of infectious diseases has accelerated in recent years. Most emerging infectious diseases are zoonotic, and many have wildlife origins (1,6). Investigations of newly identified infectious diseases, such as severe acute respiratory syndrome (SARS) and Nipah virus infection, have historically been reactive, requiring the sudden application of resources to the investigation and control of an outbreak. A proactive approach involving enhanced scientific and surveillance efforts in areas identified as emerging infectious disease "hotspots" during periods when there is no known epidemic might improve the detection of novel pathogens or recognition of outbreaks.
Through programs such as the Nigerian FELTP, the epidemiologic and laboratory resources needed to identify pathogens and outbreaks are now reaching areas of the world where resources have previously been limited. The investigation in Idanre is an example of an FELTP investigation of an activity that puts persons at risk for pathogen exposure. Particular topics for further evaluation include the factors that promote pathogen transmission from bats to humans, such as habitat encroachment and trade in bushmeat (1). Public health interventions to improve access to rabies vaccine and personal protective equipment for persons at risk for bat exposures are likely to be beneficial.

Increase in Vibrio parahaemolyticus Infections Associated with Consumption of Atlantic Coast Shellfish -2013
Anna E. Newton, MPH 1 , Nancy Garrett 1 , Steven G. Stroika 1 , Jessica L. Halpin, MS 1 , Maryann Turnsek 1 , Rajal K. Mody, MD 1 (Author affiliations at end of text) Vibrio parahaemolyticus (Vp) is found naturally in coastal saltwater. In the United States, Vp causes an estimated 35,000 domestically acquired foodborne infections annually (1), of which most are attributable to consumption of raw or undercooked shellfish. Illness typically consists of mild to moderate gastroenteritis, although severe infection can occur. Demographic, clinical, and exposure information (including traceback information on implicated seafood) for all laboratory-confirmed illnesses are reported by state health departments to CDC through the Cholera and Other Vibrio Surveillance system. Vp isolates are distinguished by serotyping (>90 serotypes have been described) and by pulsed-field gel electrophoresis (PFGE).
Vp serotypes O4:K12 and O4:K(unknown) comprise the Pacific Northwest (PNW) strain and, within the United States, had not been associated with shellfish outside the Pacific Northwest before 2012. During May-July 2012, Vp of the PNW strain associated with shellfish from Oyster Bay Harbor in New York caused an outbreak of 28 illnesses in nine states. Simultaneously, Vp of the PNW strain caused an outbreak of illnesses on a cruise ship docked on the Atlantic Coast of Spain; illness was associated with cooked seafood cooled with ice made from untreated local seawater. All Vp isolates from ill persons in the U.S. and Spanish outbreaks that were further subtyped were indistinguishable by PFGE (2).
In 2013, this same indistinguishable strain was traced from shellfish consumed by ill persons to a larger area of the U.S. Atlantic Coast, causing illness in 104 persons from 13 states during May-September (Figure). The median age of patients was 51 years (range = 22-85 years); 62% were male. Six (6%) patients were hospitalized; none died. Multiple outbreaks appeared to be occurring, accounting for many of these illnesses. Illness was associated with consumption of raw shellfish and seafood traceback was reported for 59 (57%) illnesses. Of these illnesses, 51 (86%) involved seafood that could be definitively traced to a single harvest area. The implicated harvest areas were located in Connecticut (20 illnesses), Massachusetts (15), New York (10), Virginia (four), Maine (one), and Washington (one). The remaining eight illnesses with traceback information involved seafood that could not be definitively traced to a single harvest area (locations reported included harvest areas of the Atlantic Coast of the United States and Canada). In response to the illnesses, four Atlantic Coast states closed implicated harvest areas; two issued shellfish recalls (3). The number of foodborne Vp cases in the United States traced to Atlantic Coast shellfish was threefold greater This PNW strain is possibly becoming endemic in an expanding area of the Atlantic Ocean. The mechanisms for this introduction are not known. During the 2014 Vibrio season, beginning in the spring, clinicians, health departments, and fisheries departments should be prepared for the possibility of shellfish-associated diarrheal illness caused by this strain again. Appropriate actions, such as quick closure of implicated harvest areas, will help prevent additional illnesses. The Interstate Shellfish Sanitation Conference maintains a list of shellfish harvest area closures and recalls.* Clinicians seeking an etiology of diarrhea in a patient who has recently consumed raw or undercooked shellfish should notify the microbiology laboratory that Vp is suspected; the use of special culture media (thiosulfate citrate bile salts sucrose) facilitates identification of Vibrio species. Consumers can reduce their risk for Vp infection by avoiding eating raw or undercooked shellfish, especially oysters and clams. †

Recommendation Regarding Reducing Alcohol-Impaired Driving -Community Preventive Services Task Force
The Community Preventive Services Task Force has posted new information on its website: "Reducing Alcohol-Impaired Driving: Publicized Sobriety Checkpoint Programs." The information is available at http://www.thecommunityguide. org/mvoi/aid/sobrietyckpts.html.
Established in 1996 by the U.S. Department of Health and Human Services, the task force is an independent, nonfederal, uncompensated panel of public health and prevention experts whose members are appointed by the Director of CDC. The task force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.